“Near Miss” General Instructions / Distribution

This program is intended for the express use of Montgomery County Government Employees and volunteers.

For purposes of this form, a “Near Miss” incident is an unplanned event that did not result in an on-the-job employee injury, death or damage.

A faulty process or management system invariably is the root cause for the increased risk that leads to the near miss and should be the focus of improvement.

Reporting of “Near Miss” events enables the County Government to use the information to help prevent future incidents and the possibility of future injuries.

• Answer all questions as completely as possible.
• Be sure to include the date of the incident and the Department involved, (may not be the Department you are assigned to).  This will help us properly review the policies and procedures which are affected by the “Near Miss” incident.
• This process and the submission is completely anonymous, you will not be contacted and you will not receive any feedback as to the outcome of this submission.
• When you submit the form, you will see a confirmation notification which confirms that the form has been entered into the system.